Every finding on record at Tlec Corp

It is required that each patient’s individualized written plan of care include measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the goals on the patient's plan of care were measurable. CLINICAL RECORD 8: The patient elected the hospice benefit on 11/21/2025, diagnosed with malignant neoplasms of the thyroid and secondary neoplasms of the lymph nodes. The plan of care for the benefit period from 11/21/2025 to 02/18/2026 (POC) was reviewed. During the Registered Nurse (RN) initial assessment on 11/21/2025, the RN assessed the patient’s pain level at 2/10, with the patient's goal for pain set at 5. The patient's medication regimen included gabapentin 600 mg at bedtime for neuropathic pain, oxycodone 10 mg every 4 hours as needed for pain, and Reflexive Sympathetic Dystrophy (RSD) Neuropathy Cream for topical pain relief every 6 hours as needed. Pain management was addressed in the POC at admission, with interventions to regularly assess the patient's pain level and educate them on the pain medication regimen. The POC documented the patient's goal for pain: "comfortable" pain level. "Comfortable" level of pain was not defined and is not a measurable outcome. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/05/2024 with a diagnosis of chronic systolic congestive heart failure. The skilled nursing (SN) visit notes dated 08/04/2025 and 08/07/2025 documented the patient's pain level as 4/10, while the patient's goal was set at 5. The patient's medication regimen included Tramadol 50 mg at bedtime for pain relief and a Lidocaine 4% Topical Patch applied every 12 hours as needed for pain. Pain management was addressed in the patient's POC for the benefit periods from 07/29/2025 to 09/26/2025 and 09/27/2025 to 11/27/2025, which included interventions to assess the patient's pain level, educate the patient on their medication regimen, and evaluate the effectiveness of the pain medications. The POCs documented the patient's goal for pain: “acceptable” level. "Acceptable" level of pain was not defined and is not a measurable outcome. During a joint clinical record review and interview on 12/03/2025, the Director of Health Services (DHS) stated that nurses document pain assessments and the patient's pain goals in the visit notes. However, when asked to identify where this information was included in the POC, the DHS acknowledged that the patient’s stated pain goals, as reflected in the visit notes, were not incorporated into the POC.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions from the Registered Nurse to meet the patient's needs. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/05/2024 with a diagnosis of chronic systolic heart failure. The patient resided at a nursing facility. The plans of care (POC) for the benefit periods from 07/29/2025 to 09/26/2025 and 09/27/2025 to 11/27/2025 ordered Hospice Aide (HA) services twice a week. The HA care plans dated 07/16/2025 and 09/09/2025 assigned the HA the task of a shower using a chair or, if the patient refused, a bed bath, each visit. The wound care order dated 08/01/2025 ordered the stage 3 left trochanter wound to be dressed every three days: clean the wound with cleanser, pat dry with gauze, pack with iodoform packing, cover with 4 x 4 gauze, and secure with a 6 x 6 hydrocellular border gauze. The Registered Nurse (RN) did not update the HA care plan to include instructions for the HA should the dressing become soiled, wet, or dislodged during the bath. During a joint clinical record review and interview on 12/03/2025, the Director of Health Services (DHS) [Personnel Record 3], the DHS confirmed that the HA care plan did not include information regarding the patient's wound.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed of patients with Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) reported changes in the care plan and patient needs to the Registered Nurse (RN). CLINICAL RECORD 12: The patient elected the hospice benefit on 02/05/2024 with a diagnosis of chronic systolic heart failure. The patient resided at a nursing facility. The plans of care (POC) for the benefit periods from 07/29/2025 to 09/26/2025 and 09/27/2025 to 11/27/2025 ordered Hospice Aide (HA) services twice a week. The HA care plans dated 07/16/2025 and 09/09/2025 assigned the HA the tasks to apply deodorant and lotion, assist the patient to the bathroom, help with dressing, provide a shower using a chair or a bed bath if the shower was refused, brush the patient's teeth, comb/brush their hair, and wash their hair, every visit. On 08/05/2025, the HA documented that all interventions were refused, except for washing the patient's hair, combing/brushing their hair, and applying lotion. For the subsequent HA visits on 08/12/2025 and 08/26/2025, all interventions were recorded as refused, except combing/brushing the patient's hair. The HA did not document that the RN was notified that the care plan could not be performed as assigned. CLINICAL RECORD 13: The patient elected the hospice benefit on 08/28/2025 with a diagnosis of vascular dementia with behavioral disturbance. The patient resided at a nursing facility. The POC for the benefit period from 08/28/2025 to 11/25/2025 ordered HA services twice weekly. The HA care plans dated 08/28/2025 and 09/09/2025 assigned the HA the tasks to provide a shower using a chair, give a bed bath if the shower was refused, brush the patient’s teeth, comb/brush their hair, shave, apply lotion, and use barrier cream. On 09/08/2025, the HA documented that the shower, bed bath, shave, combing/ brushing hair, and brushing teeth were all refused. During the HA visit on 09/15/2025, both brushing the patient’s teeth and shaving were marked as refused and not performed. The HA did not document that the RN was notified that the care plan could not be performed as assigned. During a joint clinical record review and an interview on 12/03/2025, the Director of Health Services (DHS) confirmed the findings, stating that these refusals were not considered a persistent problem among the patients and believed that nurse notifications were only necessary if refusals or incomplete tasks by the aide became a recurring problem.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: the needs and concerns of patients and families coping with a terminal illness; and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by interview and review of personnel records. 1 of 10 (10%) personnel records reviewed revealed the agency did not ensure each employee received an initial orientation at hire. Staff 2: The Registered Nurse's (RN) date of hire to the associated home health agency was 10/8/2018. The employee transitioned to a RN role in the hospice agency. There is no documentation of the initial orientation to hospice in the employee file. During interview with the Director of Healthcare Services on 1/18/2023 and 1/19/2023, he stated he was unable to find documentation of the RN's orientation to the hospice program.